Managing your perimenopausal years well has a singular importance for your general health and the future good function of mind, muscle, joints and bone. This significantly depends on whether you retain the powerful protective benefits of sex hormones.
Throughout the reproductive years women have secreted estrogens and progesterone from their ovaries on a cyclical basis, maximally secreting estrogen at the time of ovulation in the second week of a cycle lasting about 28 days, while progesterone is secreted from the corpus luteum, in the third and fourth week of the cycle, following ovulation. When ovulation finally ceases at the menopause estrogen is no longer secreted by the ovary but continues to be produced in lesser amounts by the fat cells of adipose tissue.
It is the abrupt lowering of estrogen levels at the menopause which is the immediate cause in some women of hot flushes, night sweats, mood swings, loss of libido, vaginal dryness and mental ‘fluffiness’. In the musculoskeletal system there may be fatigue, backache, stiffness and reduced mobility, co-ordination and strength. Estrogens (principally estradiol) exert an important restraining influence on bone resorption and in post-menopausal women they have been shown to protect against the development of osteoporosis and hip and vertebral fractures.
In their lifetime women are three times as likely as men to suffer from fractures. This may reflect the protective action in men of continuing androgen production. Older men also have high estrogen levels, relative to young men, and the estrogen appears to maintain bone mass better than does testosterone. Whilst men do not usually have women’s abrupt reduction in sex hormones at the menopause they do have declining levels which can give rise to comparable symptoms from the sixth decade onwards. This is sometimes termed the andropause. Symptoms include aching joints and muscles, stiffness, loss of mobility, sweating attacks, reduced libido, hair growth and energy. With appropriate precautions androgen replacement can be beneficial.
The case for using hormone replacement therapy (HRT) to help with immediate symptoms of the menopause remains clear and uncontroversial. Where the womb has been removed it is not considered necessary to give accompanying progesterone. Estrogen only therapy, preferably by the transdermal route, is safe. However, the long-term use of estrogens (2 or more years) with progesterone (to reduce the risk of endometrial cancer) is controversial despite its undoubted long-term benefit in maintaining bone density.
It requires balancing the risk, principally of breast and uterine cancer, and possible benefits (reduced fracture risk, vitality and well-being) to you as an individual. It is a decision best made by you with the help of your doctor. A family history of the above cancers, a blood clot in the veins of your legs, or previous liver disease means you have a greater risk when taking HRT. Identification of the specific genes (polymorphisms) predisposing to breast cancer is now possible taking a buccal smear and, despite a family history of breast cancer, can indicate whether you carry the risk-enhancing gene or not.
There are newer alternatives to HRT: Tibolone is a synthetic steroid with estrogenic, progestogenic and androgenic properties and acts as a continuous combined product. It also improves libido and has fewer effects on breast tissue. SERMs (selective estrogen receptor modulators), such as raloxifene, act at sites in bone but do not in breast and uterus. They are indicated for the treatment of osteoporosis.
Phytoestrogens are part of a large group of plant chemicals (phytochemicals) with medicinal properties. They include the isoflavonoids present particularly in soya products (for example soy flour, tofu) and linseed; and Lignins, present in whole-grain cereals, pulses and fenel. Phytoestrogens are weakly estrogenic and are used to protect against breast and prostate cancer and to help maintain bone density.
Influences on the function of muscles, joints and bone include:
Folic acid: sources include leafy green vegetables, nuts, beans, liver and kidney. Problem for which used: osteoporosis and support (mesenchymal) tissues.
Vitamin D: sources are oily fish, fortified products and sunlight. Problems for which used: osteoporosis, poor calcium absorption, healthy nerves and muscles.
Vitamin E: sources include leafy green vegetables, whole grains, beans and vegetable oils. Problem for which used osteoarthritis.
Calcium: sources include milk and dairy products, green leafy vegetables, citrus fruits, peas and beans. Used to prevent osteoporosis and for healthy nerves and muscles. Recommended intake of 1000mg/d and 1500mg if osteoporotic.
Magnesium: sources include leafy green vegetables, nuts, soya products and whole-grains. Problem for which used: osteoporosis and to maintain muscle function.
Zinc: Sources are seafood, meat, liver, eggs and poultry. Problem for which used: osteoporosis.
Protein intake: Our body is composed of about 20% protein and it is the major constituent of muscle and bone. Its basic set of molecules are the amino-acids of which twelve are made in the body and the remaining eight are obtained directly from the diet. These are termed essential amino acids. A constant supply of protein is needed to maintain bone and muscle turnover. The recommended intake of protein is 45G for women and 55G for men. This amount is readily available in a varied western diet obtained from meat and fish, eggs, cheese, milk, peas, beans, nuts, lentils and whole grains.
Water: drink, if you can, 8 glasses of water daily.
Exercise: The benefits of aerobic exercise in the prevention of cardiovascular disease is well recognised. A minimum of 45 minutes moderately strenuous exercise three times per week is recommended though finding effective ways to build rewarding physical activity into your lifestyle as routine may be as important, for instance dancing, rambling, gardening and golf. Recently it has become evident that progressive resistance training carries most benefit in improving muscle strength and, functionally, in such activities as climbing stairs, lifting and increased speed of walking. Furthermore mood is elevated, sleep improved and weight management becomes less of an issue.